APPLICATION FOR CREDIT CARD
I wish to apply for Rupay Credit Card
□Platinum □Select
Visa Credit Card □Bharat □Gold □Platinum
INSTRUCTIONS TO FILL UP THE APPLICATION FORM
1 Fill all columns with requisite details in CAPITAL LETTERS. Please paste
your recent
2. Proof of annual income and PAN Card copy is mandatory.
passport size
3. Please sign in full in the space provided and on the 2nd page of the application form.
4. Terms and conditions and card member agreement are available at Indian bank Branches and on the color
website www.indianbank.in which may be referred before applying for the card. photographhere
Please sign here in black ink
PERSONAL INFORMATION
Name:Mr./Mrs./Ms./Dr./Prof. □□□□□□□□□□ □□□□□□□□□□ □□□□□□□□□□□
First Name Middle Name Last name
Date of birth: □□ □□ □□□□ Sex: Nationality □□□□□□□□□□
□ Resident □ NRI
Legal Status: No. of Dependents: □□
PAN No □□□□□□□□□□ Passport No□□□□□□□□□ Place of Issue ….…………………………
Voter’s ID□□□□□□□□□ Driving License No. □□□□□□□□□□□ Place of Issue…………………
Vehicle Make .......................... Regn No□□□□□□□□□
RESIDENCE
Personal
Email ID …………………………………………... Land Mark ……………………………………………..
Personal Email ID …………………………………………... Land Mark …………………………………………..
Current Living with: EMPLOYMENT DETAILS
residence is □ Par Occupation: If Salaried, Industry details :
□ Owned ents
□ Salaried employed with:
□ Aviation/Hospitality □ IT/Telecom
□ □ Sp Whether Confirmed □ PSU/Govt
Fa ouse □ Banking/Finance□ Travel/Tourism
mily
Owned □ Chi □Yes □ No □ Public ltd
□ Rented ldren
□ Professional / Self- □ Private ltd □Mfg/Engg □ Entertainment/Media
□ Alo □ Real Estate/Construction
□ Comp ne
Employed Details :
□ Partnership
any leased
Period of stay: □ Oth
…………………. ….
□ Proprietorship □Others (please specify) …………
………… ers □ Retired □ Student ……………… ………………………...
Months
□ Housewife
Company/Employer Name : ………………………………….…………………………………….…………………………..
Employee (Applicant’s) Designation……………………………. Emp. No./ID / SR No………………………………………..
Office Address: ……………………………………………………………………………………………………………………
City/State.……………………….. Pin……………….. Official Email ID.………………………………………………………
Tel no. (with STD code) ………………………… Fax ……………………..……… Mobile ……………………………
FINANCIAL INFORMATION
Name of your Banker: …………………………
Branch:…………………………………………..
months
Source:…………………………………………..
DETAILS OF CREDIT CARDS HELD
SNO ISSUING BANK/INSTITUTIONS CARD NO CREDIT LIMIT (RS)
1 ………………………..
□□□□ □□□□ □□□□ □□□□ □□□□□□□□□
2. ….. ……………………..
□□□□ □□□□ □□□□ □□□□ □□□□□□□□□
DOCUMENTS ATTACHED
Copies of: □ Statement of Accounts for last 3 months (other than Indian Bank) □ IT Proof/Latest Pay Slip
□ PAN Card*** □Age Proof □ Passport □ Driving License □ Voter’s ID
BILLING INSTRUCTIONS
Mail my billing statements to
□
Current Residential Address □
Official Address
Do you want automatic debit on your Indian Bank A/c? ( for Indian Bank Customers only)
□ Yes □ No
If yes, A/c type: □
Savings □ Current Branch: …………………………… Account No. ……………………….
Amount to be debited:
□ Full amount due □ Minimum amount due □ ECS Debit*
* A copy of the cheque leaf / cancelled cheque leaf issued by the existing bank to be enclosed.
DECLARATION
Assignment clause for insurance cover: I, …………………………………………………..do hereby assign the money
payable in the event of my death by the United India Insurance Co. Ltd., to (Name)………………………………..(relation to the insured)
..................................and I further declare that his/her receipt shall be sufficient discharge to the Company.
I hereby declare that I has personally read and understood the terms and conditions governing the issue and usage of the credit card. I
verify that the contents stated in the above application are true to the best of my knowledge. I hereby authorize the Bank and/or its
associates to verify any information provided in this application form at any given time. I also confirm that I shall promptly inform the
Bank of any change in the information mentioned above. The Bank may further use the said information for marketing, administrative
and for other value addition purposes. I agree that the Card will be issued to me upon the prevailing Terms and Conditions (which are
subject to change from time to time) of the Card Member Agreement. I, as the applicant of the Primary Card, shall be liable for all
charges incurred on the Primary Card and all Additional Cards on my account. For any enhancement of credit limit, I shall undertake to
specifically apply for banks consideration.
Place Date: Signature of Applicant
RECOMMENDATION BY BRANCH : IBGA CODE : 3. Value of connections:
1. KYC requirements have been fulfilled. 2. Recommended for issue of Credit Card _________________________________
Branch Manager’s
Customer Identification No.CIF: signature
Name Specimen
signature No.
Branch : Date:
